FREEDOM OF INFORMATION REPORT Facility Information Permit: Audit Information RTF-0014 F a c i l i t y N a m e : PALMETTO PEE DEE RESIDENTIAL TREATMENT CENTER Address: 601 GREGG AVE STE B C i t y / S t a t e / Z i p : FLORENCE, SC 29501-4316 Florence Phone 1: 843-667-0644 Email: GREGORY.JOHNSON@UHSINC.COM                                                                           Audit Name: RTF ROV 20161020 Type: L07 Investigation Start Date: 02 May 2017 10:00 AM End Date: 02 May 2017 02:00 PM Inspector: Jovonya Key  Overall Score 0.0%                                                                           Audit Level Notes: Removed citation 400.A per request of Reconsideration of Cited violation by the Facility. (AS(6/22/2017) Report Notice Question ID NOTICE01 Question Bureau of Health Facilities Licensing 2600 Bull St Columbia SC 29201-1708 Answer Report Notice REPORT NOTICE: If applicable, this Report of Visit includes a detailed description of the conditions, conduct or practices that were found to be in violation of requirements. This inspection or investigation is not to be construed as a check of every condition that may exist, nor does it relieve the licensee (owner) from the need to meet all applicable standards, regulations and laws. The South Carolina Code of Laws requires this Department to establish and enforce basic standards for the licensure (permitting), maintenance, and operation of health facilities and services to ensure the safe and adequate treatment of persons served in this State. It also empowers the Department to require reports and make inspections and investigations as considered necessary. Furthermore, the Code authorizes the Department to deny, suspend, or revoke licenses (permits) or to assess a monetary penalty against a person or facility for (among other reasons), violating a provision of law or departmental regulations or conduct or practices detrimental to the health or safety of patients, residents, clients, or employees of a facility or service. If applicable to the type of report being made, the signature of the activity representative indicates that all of the items cited were reviewed during the exit discussion. If this Report of Visit is required by regulation to be made available in a conspicuous place in a public area within the facility, redaction of the names of those individuals in the report is required as provided by Sections 44-7-310 and 44-7-315 of the S.C. Code of Laws, 1976, as amended. Administrator's Signature - Plan of Correction Question ID Question Answer SIGN01 PLAN OF CORRECTION - Administrators Certification: I certify that the attached plan of correction describes: (1) the actions taken to correct each cited deficiency, (2) the actions taken to prevent similar recurrences, and (3) the actual or expected completion dates of those actions. POC REQUIRED PRINT NAME:__________________________________________________________________________ TITLE:_______________________________________________________________________________ SIGNATURE:___________________________________________________________________________ DATE:________________________________________ Any violations cited in this report of visit were observed at the time of the inspection. The Administrator submits an electronic plan of correction by visiting the website http://www.scdhec.gov/Health /FHPF/HealthFacilityRegulationsLicensing/HealthcareFacilityLicensing/CorrectionPlan/ and following the instructions online. Or the Administrator returns a copy of this report (original signature required) with description of corrective actions to: SCDHEC, Bureau of Health Facilities Licensing, 2600 Bull St, Columbia, SC, 29201 Your response to this report must be received in our office by close of business (5:00 p.m.) no later than the date listed below: Comments     •   The Plan of Correction (POC) is due fifteen (15) days from receipt of this Report of Visit (ROV). Inspection Information Question ID Question Answer COMBO-LIC Inspection Includes Licensing: YES COMBO-FOOD Inspection Includes Food/Sanitation: NO COMBO-FLSC Inspection Includes Fire & Life Safety: NO ONSITE Is this an On-Site Visit? YES INSP Select the Type of Inspection to be Performed: COMPL-01 Section Team Log Number: Comments     •   M04033-17 COMPL-03 Reason for Investigation: Comments     •   A complaint (M04033-17) was received by the Department on (04/19 /2017). The complaint alleged the following: RTF Complaint Investigation Section Team Log Number Reason for the Investigation. A. Staff is asleep during work. B. Resident took staff keys. COMPL-04 What is the Source: COMPL-10 Date Agency (DHEC) Notified: Comments     •   04/19/2017 COMPL-05 Detailed Results of this Investigation: Comments Consumer Complaint Date Agency (DHEC) Notified: Detailed Results     •   To investigate this complaint, a visit was made to the facility by (4) representatives of the Department. The investigation consisted of the following: 1. A review of resident records to include but not limited to: care plans, monthly observation notes and monitoring sheets. 2. A review of incident/accident reports. 3. A walk through of the facility. 4. A review of facility's handbook. 5. A review of facility's Employee Conduct and Work Rules policy, Resident Observation policy and Staff to Client Ratio policy. 6. Interviews with staff and resident. 7. A review of personnel records to include background checks, training and termination documents. 8. A review of Daily Staff Assignment Verification Reports to include time cards. 9. A review of surveillance footage. As a result of the investigation, the following violations of Standards for Licensing Residential Treatment Facilities for Children and Adolescents: 7 S.C. Code Ann. Regs. 61-103 (Supp.2016) were cited. COMPL98 Is this an Unlicensed Facility/Activity Complaint? NO COMPL-06 Has the Initial QI Review Been Completed? NO VERIFY02 Is the Current Facility/Activity Administrator the same as the Administrator of Record? Comments NO     •   No. Rickie Grant INSP04 Are there any other individuals accompanying the auditor for this visit? Comments     •   YES Vanessa Stafford, Field Manager Joan Morton, RN Lorie Sanders, LPN RTF Regulation Sections 500 -1300 Question ID Question R61-103-1002.A3 1002.A.3. Each resident shall be afforded the following rights: 3. The right to a safe, secure, and clean environment; (Class II Violation) Comments     •   Resident B was not afforded the right to a safe and secure environment. Surveillance footage dated and time-stamped at showed Staff A searching a bedroom occupied by Resident B and two (2) other residents. Staff A exited the bedroom and then re-entered the bedroom moments later, at which point, Staff A physically attacked Resident B. Staff A was observed punching Resident B and placing Resident B in a head-lock position. The physical altercation took place for greater than two (2) minutes (as time-stamped by the surveillance footage) before Staff B entered the room and separated Staff A and Resident B. Answer OUT Record Retention Question ID RETENTION Question DHEC 0282 (05/2010) AUDIT - [Records Retention Schedule #SBH-F&S-17] Answer Retention 7/20/2018 ReadOnlyPOC PLAN OF CORRECTION REPORTING FORM BUREAU OF HEALTH FACILITIES LICENSING INSPECTION INFORMATION License Number: RTF-0014 Facility Type: HL- Residential Treatment for Children & Adolescents Facility Name: PALMETTO PEE DEE RESIDENTIAL TREATMENT CENTER Inspection Date: 05/02/2017 Submission Date: 05/26/2017 Type of Inspection: Investigation ADMINISTRATOR'S CERTIFICATION By checking this box, I attest that I am the administrator of the facility/activity and that this plan of correction is accurate. Additionally, I certify that the plan of correction describes the actions taken to correct each cited deficiency, the actions taken to prevent similar recurrences and the actual or expected completion date. Checked Administrator Name: Shannon Marcus E-mail: shannon.marcus@uhsinc.com Phone: (803) 791-9918 RESPONSE TO CITATIONS Section: 1002.A.3 Was Completion Date Provided? Completion Date (Actual or Expected): 04/10/2017 Corrective Action: Upon doing a review of camera footage this incident was found and the employee was immediately terminated on reported to mandated regulatory bodies including SC DHEC. All information was Preventive Action: Facility Leadership will continue to conduct random reviews of cameras as well as do in person random leadership rounds. In addition, facility will continue to provide staff training on appropriate supervision guidelines of patients and approved behavioral interventions with patients. Optional Comments: Response Approved: Yes LOG INFORMATION SECTION http://intraprod/PlanOfCorrection/(X(1)S(f3reruvul143on3tgqaabhmb))/FormSessionRenderReadOnlyPOC.aspx?formSessionId=17610 1/2 7/20/2018 ReadOnlyPOC Report of Visit Delivery Date: 5/16/2017 Plan of Correction Due Date: 5/31/2017 Date Plan of Correction was Reviewed: 07/03/2017 Reviewed by: VS Comments: Plan of Correction Approved: Yes Decision By: V.Stafford Decision Date: 07/03/2017 Remove POC: UPLOAD DOCUMENTS File Upload iPalmettpPeeDee_POCAcceptance.pdf (FileHandler.ashx?formItemResponseFileId=1777) Plan of Correction Log Number: MPC05099-17 DHEC Form 0284 (05/2014) http://intraprod/PlanOfCorrection/(X(1)S(f3reruvul143on3tgqaabhmb))/FormSessionRenderReadOnlyPOC.aspx?formSessionId=17610 2/2   FREEDOM OF INFORMATION REPORT Facility Information Permit: Audit Information RTF-0014 F a c i l i t y N a m e : PALMETTO PEE DEE RESIDENTIAL TREATMENT CENTER Address: 601 GREGG AVE STE B C i t y / S t a t e / Z i p : FLORENCE, SC 29501-4316 Florence Phone 1: 843-667-0644 Email: GREGORY.JOHNSON@UHSINC.COM                                                                           Audit Name: RTF ROV 20161020 Type: L07 Investigation Start Date: 02 May 2017 09:35 AM End Date: 02 May 2017 02:00 PM Inspector: Lorie Sanders 100.0%                                                                           Question Answer  Overall Score Report Notice Question ID NOTICE01 Bureau of Health Facilities Licensing 2600 Bull St Columbia SC 29201-1708 Report Notice REPORT NOTICE: If applicable, this Report of Visit includes a detailed description of the conditions, conduct or practices that were found to be in violation of requirements. This inspection or investigation is not to be construed as a check of every condition that may exist, nor does it relieve the licensee (owner) from the need to meet all applicable standards, regulations and laws. The South Carolina Code of Laws requires this Department to establish and enforce basic standards for the licensure (permitting), maintenance, and operation of health facilities and services to ensure the safe and adequate treatment of persons served in this State. It also empowers the Department to require reports and make inspections and investigations as considered necessary. Furthermore, the Code authorizes the Department to deny, suspend, or revoke licenses (permits) or to assess a monetary penalty against a person or facility for (among other reasons), violating a provision of law or departmental regulations or conduct or practices detrimental to the health or safety of patients, residents, clients, or employees of a facility or service. If applicable to the type of report being made, the signature of the activity representative indicates that all of the items cited were reviewed during the exit discussion. If this Report of Visit is required by regulation to be made available in a conspicuous place in a public area within the facility, redaction of the names of those individuals in the report is required as provided by Sections 44-7-310 and 44-7-315 of the S.C. Code of Laws, 1976, as amended. Inspection Information Question ID COMBO-LIC Question Inspection Includes Licensing: Answer YES COMBO-FOOD Inspection Includes Food/Sanitation: NO COMBO-FLSC Inspection Includes Fire & Life Safety: NO ONSITE YES Is this an On-Site Visit? INSP Select the Type of Inspection to be Performed: COMPL-01 Section Team Log Number: Comments RTF Complaint Investigation Section Team Log Number     •   M04035-17 COMPL-03 Reason for Investigation: Comments     •   A complaint M04035-17 was received by The Department on April 11, 2017. Resident A was in altercation with a staff member on COMPL-04 What is the Source: COMPL-10 Date Agency (DHEC) Notified: Comments Consumer Complaint Date Agency (DHEC) Notified:     •   April 11, 2017 COMPL-05 Reason for the Investigation. Detailed Results of this Investigation: Comments Detailed Results     •   To investigate the complaint, a visit was made to the facility by 4 (four) representative of The Department. The investigation consisted of, but was not limited to: 1. Interview with the Administrator, Chief Operations Manager, Risk Manager, and Staff Members. An interview with Resident A who stated there has been no incidents that involved he/she in an altercation with a staff member. 2. A review of the facility incident and accidents report for April 2017. 3. A review of Resident's A care and treatment plan, physicians orders, weekly nursing summaries for the month of April 2017, nursing progress notes for March and April 2017. 4. A review of Resident's A observation notes for the month of April 2017, seclusion and CPI occurrences for March and April 2017. Therapy/case management notes for the month of April 2017, and psychiatric progress notes for April 2017. As a result of the investigation, no violations of (Regulation 61-103), Residential Treatment Facilities for Children and Adolescents were cited. COMPL98 Is this an Unlicensed Facility/Activity Complaint? NO COMPL-06 Has the Initial QI Review Been Completed? NO VERIFY02 Is the Current Facility/Activity Administrator the same as the Administrator of Record? YES INSP04 Are there any other individuals accompanying the auditor for this visit? Comments YES     •   JoVonya Key, Investigator III Vanessa Stafford, Investigator Joan Morton, RN, investigator Record Retention Question ID RETENTION Question DHEC 0282 (05/2010) AUDIT - [Records Retention Schedule #SBH-F&S-17] Answer Retention